Olivia McRitchie
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NCLEX Nursing (Medical-Surgical) Quiz am Exemplar 16.1: Pulmonary Embolism, erstellt von Olivia McRitchie am 08/12/2018.

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Olivia McRitchie
Erstellt von Olivia McRitchie vor etwa 6 Jahre
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Exemplar 16.1: Pulmonary Embolism

Frage 1 von 10

1

You are tasked with teaching a fellow nursing student about pulmonary embolisms as part of an in class activity.

Select the information that is correct.

Wähle eine der folgenden:

  • "The most common thrombi to embolize to pulmonary circulation are thrombi of the deep veins of the calf."

  • "Pulmonary embolisms can cause sudden death."

  • "More often than not, pulmonary embolisms cause lung tissue infarction."

  • "Pulmonary embolisms can lead to systemic hypertension and right ventricular heart failure."

  • "The body is usually unable to dissolve the clot."

  • "Fat emboli are nonthrombotic. They usually occur after any sort of bone fracture."

Erklärung

Frage 2 von 10

1

You are taking care of a 40-year-old female patient following a knee replacement. She is complaining of chest pain, coughing, nervousness, and inability to breathe. You are incredibly concerned because her MAR shows that her first dose of enoxaparin was not administered.

What might you be looking for when you assess this patient?

Wähle eine oder mehr der folgenden:

  • Tachycardia

  • Tachypnea

  • Crackles upon auscultation of lungs.

  • Low-grade fever

  • An S3 and/or S4 gallop

  • Diaphoresis

  • Cyanosis in fingers, toes, and lips

Erklärung

Frage 3 von 10

1

Which of the following is NOT an intervention for a patient experiencing hypoxia due to blockage of alveoli by thrombus?

Wähle eine der folgenden:

  • Administer oxygen.

  • Place the patient in high Folwer's position

  • Prepare for intubation and mechanical ventilation.

  • Procure prescription for 5,000 U of heparin, IV bolus.

  • Monitor ABGs and aPTT (or PTT)

  • Maintain an environment with minimal sound and minimal light.

  • Suction PRN

Erklärung

Frage 4 von 10

1

Select the interventions that would be appropriate for a patient whose small arterioles are rupturing due to arterial congestion.

Wähle eine oder mehr der folgenden:

  • Educate patient and family about hemoptysis.

  • Procure an order for oxygen at a flow rate of 2 mL via nasal cannula.

  • Perform suctioning when airway becomes too occluded.

  • Position patient in a high Fowler's position.

  • Administer prescribed antibiotics.

Erklärung

Frage 5 von 10

1

You have a patient with alveolar collapse r/t tissue necroses and inflammation and pyrexia r/t the inflammatory process. You've administered oxygen, placed the patient in a high-Fowler's position, and procured sputum for laboratory testing. What other interventions can you enact?

Wähle eine oder mehr der folgenden:

  • Encourage the patient to blow into the incentive spirometer 10 times every hour.

  • Procure an order for a 5,000 U IV bolus of heparin.

  • Administer 600 mg of acetaminophen.

  • Administer prescribed antibiotics.

  • Prepare for possibility of intubation.

Erklärung

Frage 6 von 10

1

Drag and drop the correct diagnostic test for the description.

-: Shows hypoxemia (PaO2 <80 mmHg) and respiratory alkalosis (pH >7.45, PaCO2 <38 mmHg) caused by tachypnea and hyperventilation.

-: Radiotagged albumin is injected IV and distributed in the lungs by pulmonary blood flow. The lungs are then scanned for distribution of isotope; an area of the lung where it cannot be detected is suggestive of occluded blood flow and pulmonary embolism.

-: Shows pulmonary infiltration and, sometimes, pleural effusion.

-: A radiotagged gas is inhaled and the lungs are scanned for gas distribution. When in combination with a perfusion lung scan, it can identify areas of the lung that are ventilated but not perfused.

-: The PRINCIPAL test used to diagnose PE. Effectively shows large, central pulmonary emboli.

-: The DEFINITIVE test for PE when other less invasive tests aren't conclusive. A contrast medium is injected into pulmonary arteries so the pulmonary vascular system can be seen on X-ray. Makes it possible to detect very small emboli.

-: Ordered to rule out acute MI. Tachycardia and nonspecific T-wave changes are generally associated with PE.

-: Evaluates alveolar perfusion. The normal reading is 35-45 mmHg, but it is decreased when pulmonary perfusion is impaired.

-: Highly specific to presence of a thrombus. Tests for a fragment of fibrin formed during lysis of a blood clot. If elevated, it indicates thrombus formation and lysis.

Klicke und ziehe, um den Text zu vervollständigen.

    Arterial blood gas
    Perfusion lung scan
    Lung scan
    Chest x-ray
    Ventilation lung scan
    Chest CT with contrast
    Pulmonary angiography
    Electrocardiography
    ETCO2
    Plasma D-dimer levels

Erklärung

Frage 7 von 10

1

You are caring an elderly patient admitted to the ER with a pulmonary embolism. Her daughter is her primary caretaker at home. The elderly patient had a hip replacement just 4 days prior, and was sent home with a prescription for warfarin. You ask her if she took her warfarin and she explained to you that she didn't because her daughter refused to pick up the prescription, stating that it was "dangerous and unnecessary".

You speak to the daughter and she cries and states the following: "A close, trusted friend told me that warfarin is dangerous because it could cause my mother to bleed out. I looked at a couple websites that she sent me... I honestly didn't know that this would happen!" You assess that the daughter did not have malicious intent, but was uninformed about her mother's medications.

You decide to educate the daughter. Which of the following statements, made by the daughter, shows that she still needs more teaching?

Wähle eine der folgenden:

  • "My mother is at risk for pulmonary embolism because she had hip surgery."

  • "My mother is now being given an IV of heparin to prevent new clots from forming."

  • "My mother was given Coumadin to take for 3 months because it can prevent blood clotting."

  • "Major hemorrhage is common with anticoagulant therapy, but it's a necessary risk."

Erklärung

Frage 8 von 10

1

Which of the following is NOT a preventative measure that a nurse can enact to prevent DVT and pulmonary embolisms?

Wähle eine der folgenden:

  • Encouraging ambulation after surgery.

  • Compression stocking and/or pneumatic compression devices.

  • Active range of motion leg exercises.

  • Encouraging the patient to place pillows under the knees.

  • Encouraging the patient to ambulate every hour or so.

  • Teaching the patient to not cross the legs when sitting.

Erklärung

Frage 9 von 10

1

You have a new admit to the ICU. During hand-off, the med-surg RN that took care of the patient reported that she's having trouble breathing, had 10/10 chest pain, felt anxious, and couldn't stop coughing. When the RN took her vital signs, her heart rate was 110 BPM, RR 30 breaths/min, BP 104/66, temp 100.1 Fahrenheit, and SpO2 92%. She had inspiratory and expiratory crackles in her middle right lung. A chest CT on the patient showed a rather large pulmonary embolism, so the doctor has ordered a 5,000 U IV bolus of heparin, followed by a continual heparin infusion at 1,000 U/hr. The doctor has also ordered streptokinase.

Select interventions you can enact for this patient.

Wähle eine oder mehr der folgenden:

  • Reassess patient heart sounds, skin color and temp, neck veins, extremities, pulmonary arterial pressure, and respiratory status every 4 hours.

  • Place patient on constant pulse oximetry monitoring.

  • Keep the head of the bed between 45 and 90 degrees and the foot of the bed dependent.

  • Keep pressure on injection sites for 30 minutes.

  • Make sure the patient ambulates every 2 hours.

  • Assess the patient for bleeding gums, incisional bleeding, bruising of injection sites, bruising with minor trauma, joint pain, and abdominal pain at the beginning of the shift.

  • Procure an order for an arterial line.

  • Keep vitamin K readily available.

Erklärung

Frage 10 von 10

1

The "antidote" to counteract heparin is protamine sulfate

Wähle eins der folgenden:

  • WAHR
  • FALSCH

Erklärung

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